Provider Demographics
NPI:1063702314
Name:FITZGERALD, RYAN EVERETT (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:EVERETT
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:625 6TH AVE S STE 450
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4629
Mailing Address - Country:US
Mailing Address - Phone:727-898-2663
Mailing Address - Fax:727-568-6836
Practice Address - Street 1:625 6TH AVE S STE 450
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4629
Practice Address - Country:US
Practice Address - Phone:727-898-2663
Practice Address - Fax:727-568-6836
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME153854207X00000X, 207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113017600Medicaid